By Stacey Kusterbeck
Many EDs track specific clinical events known to raise the risk of a medical error. If any of these clinical events are identified, it triggers a chart review as part of the department’s quality improvement (QI) process. “Currently used triggers for the emergency department are inefficient, with positive predictive values of less than 10% for detecting medical errors,” according to Deena Berkowitz, MD, MPH, associate division chief of emergency medicine at Children’s National.
Berkowitz and colleagues recently identified a new trigger for medical error: undertriage (defined as patients with a low-acuity Emergency Severity Index score who end up admitted from the ED). “Our objectives were to determine the positive predictive value of undertriage to detect medical error, and develop a roadmap for other emergency departments to monitor and improve ED performance,” Berkowitz says.
Of 125,457 patients triaged as low-acuity in 2019-2020, 1.1% were undertriaged. Of that group of 267 patients, 127 were categorized as mistriage (defined as assigned a different level based on information available at the time of triage). (Read more here.)
The researchers found several issues were important to track using QI methods, including discrepancy in exam or history between the triage and assessment nurses, along with discrepancy between the chief complaint and the physical exam. Also, researchers found failure to synthesize historic or objective information.
Berkowitz offers three suggestions for leaders who want to use undertriage as part of their department’s QI:
• Establish some nurse/physician teams to review charts. “Creating a joint physician-nurse team is an important factor in this process. We used nurse physician dyads to review every chart,” Berkowitz says.
• Pull data from the EHR regularly. “If you have EHR support and can pull data on ESI level 4 or 5 patients who were admitted, it is easy to track undertriage rates,” Berkowitz says.
• Discuss differences of opinion between nurses and physicians on the cause of undertriage. “The team can use those discussions to develop key drivers to address the themes and categories they identified,” Berkowitz says. n
Investigators found several issues were important to track using quality improvement methods, including discrepancy in exam or history between the triage and assessment nurses, along with discrepancy between the chief complaint and the physical exam. Also, they found failure to synthesize historic or objective information.
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